A Pharmacist's Guide to OTC Therapy: Heartburn

MAY 01, 2006

Yvette C. Terrie, BSPharm, RPh

Approximately 95 million individuals in the United States (36%-40% of the population) experience heartburn or acid indigestion at least once a month. Approximately 7% of the population experiences heartburn daily.1 Fortunately, the majority of individuals experience only mild and occasional heartburn. Various factors can contribute to heartburn (Table 1).

Currently, there are nonprescription products available?including several antacids, histamine2 receptor antagonists (H2RAs), and 1 proton pump inhibitor agent?that can be used by patients for self-management of mild-to-moderate heartburn (Table 2). Pharmacists can aid patients in determining whether self-treatment is appropriate or whether they should seek immediate medical care.

Antacids

Antacids typically are utilized for treating mild and infrequent heartburn. Sodium bicarbonate, calcium carbonate, aluminum salts (hydroxide, phosphate), and magnesium salts (hydroxide, chloride) are the 4 primary neutralizing compounds available in the variety of antacids presently available over the counter. Antacid products are available as single-entity products as well as combination products. All antacid products differ significantly in potency, gastrointestinal side effects, systemic complications, and drug interactions. The majority of these properties are determined by the metal cation of the antacid and by the degree of its systemic absorption.1

Patients should be reminded that antacids containing magnesium can cause diarrhea, and those containing aluminum can cause constipation. Because antacids can affect certain prescription drugs, patients should be advised always to take antacids at least 2 hours apart from interacting agents.

Histamine2 Receptor Antagonists

H2RAs also are useful for treating mild-to-moderate heartburn. They can be used in conjunction with antacid products. Prior to recommending any of these agents, the pharmacist should carefully assess the patient's medication profile to screen for possible drug-drug interactions. For example, with the use of cimetidine, drug interactions can occur with phenytoin, theophylline, and warfarin. The most common adverse effects associated with the use of H2RAs are headache, nausea, vomiting, drowsiness, constipation, or diarrhea.

Proton Pump Inhibitors

Omeprazole is the only proton pump inhibitor available as a nonprescription product. It is another treatment option available to individuals who experience frequent episodes of heartburn (>2 times a week). It is not indicated for use in the prevention of heartburn or for immediate relief of heartburn. Patients should be informed that complete relief may not be noticed for 1 to 4 days after the first dose, and the drug should be taken daily for 14 days. Common adverse effects include headache, diarrhea, constipation, nausea, vomiting, abdominal pain, and cough.

Role of the Pharmacist

Prior to recommending any of these products, pharmacists should carefully assess the severity of a patient's symptoms to determine whether self-treatment is a viable option for the individual. The pharmacist also should evaluate the medical history and concomitant medication profile to screen for possible drug interactions or contraindications. Patients should be reminded to use these products appropriately for the recommended length of time.

Although these nonprescription products can effectively treat the symptoms associated with heartburn, individuals who experience frequent episodes of heartburn should be encouraged to contact their health care provider for additional evaluation in order to prevent further complications. Patients also should be reminded of modifications to their lifestyles that may reduce the occurrence of heartburn.